Simplifying Fat Loss - Health - Life

Please take a few minutes and answer these questions. It is very important that you approach your training in a safe manner. Once you have submitted these, I will email you a confirmation, and give you more details about your class. Thanks, Stephen

Name *

Name

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Phone

Phone

(###)

###

####

Birthdate *

How did you hear about my boot camp? *

Which class do you prefer? *

I prefer that you choose one class, but if your schedule does not allow for this, please contact me, and we will work out something for you.

Monday, Wednesday, Friday Mornings. 5:45 AM - 6:30 AM

Monday, Wednesday, Friday Evenings 6:00 PM - 6:45 PM

Tuesday and Thursday Mornings 5:45 AM - 6:30 AM

Tuesday and Thursday Evenings 6:00 PM - 6:45 PM

Drop In

Guest

Personal Training

When would you like to start? Camps can be prorated if necessary.

Medical Information

Who would you like me to contact in case of an emergency? *

Name and number of physician *

Has your doctor ever said that you have a heart condition and that you should only perform physical training under the care of a doctor?

Yes

No

Do you feel pain in your chest when you perform physical activity? *

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition *

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Do you know of any other reason why you should not engage in physical activity? If so, please let me know here. *

Has a physician ever diagnosed you as having high blood pressure? (>160/90) *

Yes

No

Are you on blood pressure medication? *

Yes

No

Regarding your cholesterol. Is the value >240 mg/dl? *

Yes

No

Do you smoke? *

Yes

No

Do you suffer from diabetes? *

Yes

No

Has anyone in your immediate family suffered coronary or atherosclerotic disease before age 55? *

Yes

No

Ladies, are you or do you think you might be pregnant? *

Yes

No

List any medications and doses you are currently taking. *

If none, just say none.

Do you have any allergies? *

If so, to what?

Do you have any physical limitations that would limit your ability to exercise? If so,what are they? *

List dates, reasons, and outcomes of any surgeries, abnormal test results, and hospitalizations which you might believe would relate to boot camp training. *

Your digital signature and date *

Goals

Do you have a specific goal? Is there a date by which you wish to achieve it? How can I help you? Are there specific areas that you want to work on? *

Please give me as much information as you think will help me in personalizing your program.

On a scale of 0-10, how important is making this change to you?

On a scale of 0-10, how confident are you that you can make this change?

What type of physical activity are you currently doing? *

What supplements are you currently taking? Vitamins, protein powder, etc.?

What do you like to do for fun?

What are your fears or worries about training/boot camp?

Informed Consent *

The exercise sessions you will become involved with and undertake will consist of progressive exercise levels and be determined and regulated by your trainer. The exercise sessions will consist of aerobic and weight training as well as education and instruction. These exercises are designed to place a gradual increasing stress on the body and as such to improve the body’s function, although no guarantee can be made. I am aware that all activities are offered as recreational or self directed in nature and I have the right and choice to stop activity at any time. I also assume full responsibility during and after my participation for any risk, discomfort or fatigue that I may experience. I understand that exercise and cardiovascular activity and the response of my body to such activity cannot be predicted. I acknowledge my responsibility and obligation to inform the nearest supervising employee of any pain, discomfort, fatigue or any other symptoms that I may suffer and that it is my choice to participate in the training program. I also understand that my trainer or other staff may not be licensed, certified, or registered instructor and that skill levels may vary and that I accept assumption of all the risk that may imply as my own. The information made and obtained during the training sessions is treated as confidential. However it may be used for statistical purpose as long as my privacy is not compromised. I understand that I may ask any questions or request further information about any of the activities, programs, or services offered at any time before, during or after participation. I may take as long as I need to think the program over and can participate now or withdraw at any time. I have read the above and consent to participate in a fitness program.

Photo-Video Release Form *

I grant to Stephen Cooper and Boot Camp Pasadena, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Stephen Cooper and Boot Camp Pasadena , its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Stephen Cooper and Boot Camp Pasadena may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.